Information Collection

Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)

IC 28212 under ICR 202404-2900-002 · OMB 2900-0067.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 21-4502 Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904) (VA Form 21-4502)	Form
21-4502 Application for Automobile or Other Conveyance and Adapt VA Form 21-4502 (OMB Exp. 7-31-24).pdf www.va.gov/vaforms	Form
21-4502 Application for Automobile or Other Conveyance and Adapt VA Form 21-4502 (Q9 7-24-24).pdf www.va.gov/vaforms	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 3.808

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4502	Application for Automobile or Other Conveyance and Adaptive Equipment (Under 38 U.S.C. 3901-3904)	VA Form 21-4502 (Q9 7-24-24).pdf	www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title: Compensation, Pension, Education, and Veteran Readiness and Employment Records-VA (58VA21/22/28)

FR Citation: 87 FR 8740

Number of Respondents: 12,786

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,786	11,141	1,645
Annual IC Time Burden (Hours)	3,197	2,786	411
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.